Obsessive compulsive disorder - OCD treatment and therapy from NOCD

How can I stop picking at my skin? What experts say

By Grant Stoddard

Jun 7, 20236 min read minute read

Reviewed byPatrick McGrath, PhD

You’re well aware of the redness, scarring, and potential for infection your habit causes—sometimes it makes you so frustrated that you’d do anything to stop. But the temporary sense of relief, gratification, or pleasure you get from it has, time and time again, felt too great to resist: you’re picking at your skin again and, despite the unsightly, painful, and potentially dangerous results—not to mention your fear of being judged—you just can’t seem to stop. 

What you might not know is that skin picking—also called excoriation disorder—is no mere quirk. It’s a recognized mental disorder that belongs to a group of clinically-defined behaviors known as body-focused repetitive behaviors (BFRBs), along with nail-biting, hair-pulling, and cheek-biting. 

In this article, we’ll look at what leads people to engage in BFRBs and how they’re distinct from normal self-grooming behaviors, how BFRBs are related to—but distinct from—obsessive-compulsive disorder (OCD), and explain how you can access the most effective treatment for managing this recognized mental disorder more easily than ever before. 

Do these experiences sound familiar? Learn how you can overcome them.

Here at NOCD, we know how overwhelming OCD symptoms can be—and how hard it is to open up about your experience. You’re not on your own, and you can talk to a specialist who has experience treating OCD.

Learn more

BFRBs explained

BFRBs, or body-focused repetitive behaviors, are a group of habits that involve repeatedly touching, picking, or pulling at the body, and they’re distinct from normal self-grooming behaviors in several ways. 

Firstly, BFRBs go beyond the typical self-grooming actions others engage in for hygiene or maintenance purposes. They involve persistent and compulsive behaviors that are difficult to control, leading to significant time and energy spent on the behavior.

Secondly, unlike a quick scratch or the plucking of a conspicuously long eyebrow hair, BFRBs often damage the body. People with BFRBs may pick at their skin until it bleeds or pull out their hair, causing noticeable bald patches.

Also, while normal self-grooming behaviors serve a functional purpose and are typically performed for an intentional, practical reason, BFRBs are often linked to emotional states such as stress, anxiety, boredom, or a need for sensory stimulation. They can act as coping mechanisms or ways to relieve tension, but they can also become addictive and difficult to stop.

Lastly, BFRBs are typically associated with distress and impairment in daily functioning. They can cause emotional distress, impact self-esteem, and disrupt social relationships. On the other hand, normal self-grooming behaviors don’t interfere with daily life, but work as a part of one’s intended lifestyle. 

Are BFRBs a type of OCD? 

In 1987, trichotillomania (hair pulling) became the first BFRB to be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), though, at the time, it was classified as an “impulse-control disorder.” The diagnostic criteria were later revised, and in May 2013, trichotillomania—along with skin picking and all other BFRBs—was included in the “obsessive-compulsive and related disorders” category. 

Other OCD-related disorders include olfactory reference syndrome (the irrational fear that you are emitting an unpleasant body odor), body dysmorphic disorder (intrusive preoccupations with a perceived defect in your appearance), and hoarding disorder (the inability to discard items even though they appear to others to have no value).    

With skin-picking disorder belonging in the OCD-related disorder category today, you’d be right to assume that these conditions have much in common. Both involve repetitive behaviors that people feel driven to perform, often resulting in distress or impairment. In OCD, the repetitive behaviors are known as compulsions, while in dermatillomania, the repetitive behavior is limited only to skin picking.

People with OCD and skin-picking disorder both experience an intense urge to engage in their respective behaviors, often feeling temporary relief or gratification afterward. Both conditions can be time-consuming, interfering with daily activities and causing significant distress. Additionally, people with OCD and skin-picking disorder often struggle with attempts to resist or control their behaviors, often experiencing feelings of shame, guilt, or anxiety when they do. 

All that said, the two disorders have one major point of difference. “The key distinction between OCD and BFRBs lies in the motivation behind repetitive behaviors,” explains therapist and NOCD’s Chief Clinical Officer Dr. Patrick McGrath. “OCD compulsions are driven by distressing thoughts, images, or urges, and the compulsion aims to alleviate anxiety or prevent harm. On the other hand, BFRBs are not necessarily triggered by intrusive thoughts but rather by physical sensations that build up until a person engages in behaviors like picking or pulling. Similarly, pleasure or satisfaction is often associated with certain aspects of BFRBs, which is not typically the case in OCD.”

Although BFRBs and OCD can coexist in the same person at the same time, it’s crucial to differentiate them because symptoms of the two conditions actually require different treatment approaches. 

Diagnosing skin-picking disorder

The DSM-5 doesn’t include a specific diagnostic category for BFRBs as a separate disorder, but instead provides criteria for two specific BFRBs: trichotillomania (hair-pulling disorder) and excoriation disorder (skin-picking disorder). 

Here is a summary of the diagnostic criteria for dermatillomania: 

  • Recurrent skin picking, resulting in skin lesions
  • Repeated attempts to decrease or stop skin picking
  • These symptoms significant distress or impairment in social, occupational, or other important areas of functioning
  • Symptoms are not the result of another condition or substance use

Access therapy that’s designed for OCD

NOCD Therapists have used ERP therapy to help thousands of people regain their lives from OCD. I encourage you to learn about accessing ERP therapy with NOCD.

Learn about ERP with NOCD

How can skin-picking be treated?

If you feel you may be suffering from excoriation disorder, it’s time to seek a proper diagnosis and get on the road to recovery with one of the most effective therapies for skin-picking disorder and all other BFRBs: habit reversal training (HRT).

Despite being re-classified as an OCD-related disorder in the DSM-5, the treatment approaches for BFRBs and OCD are somewhat different. BFRBs are most often treated with habit-reversal training (HRT), while exposure and response prevention therapy (ERP) is considered the gold standard treatment for OCD.

“HRT involves two main components. The first involves monitoring and tracking the specific details of when the problematic behavior, such as skin picking, occurs,” says Dr. McGrath. “This process helps people become more aware of their behavior patterns, triggers, and the duration of the episodes. By developing increased awareness, they can often reduce the frequency of the behavior itself.” The second component is known as competing response training. With greater awareness of their behavior and triggers, a person can intentionally respond with other actions, such as crossing their arms or gently squeezing their hands into a fist, rather than picking at their skin.

In HRT, the various circumstances in a person’s life that contribute to the pulling or picking episodes are taken into consideration. It is typically a short-term treatment, lasting around 12 therapy sessions or sometimes fewer, and has shown to be highly effective when people follow the therapist’s guidance.

ERP for OCD, on the other hand, involves exposing people to situations or triggers that evoke anxiety or distress and preventing the accompanying compulsive behaviors or rituals. The goal of ERP is to help people learn that they are able to sit with distress and uncertainty, without resorting to compulsions that only make symptoms worse.

People commonly suffer from both OCD and BFRBs, including excoriation disorder, at the same time. In these cases, skin picking and OCD compulsions may be treated together, using both ERP and HRT treatment.

Getting help

If you or someone you know is struggling with skin-picking disorder or any other BFRB, I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment with the NOCD Care Team to learn more about how a licensed therapist can help. While all NOCD therapists specialize in OCD and . receive ERP-specific training, many also specialize in treating BFRBs with HRT and have experience treating people for both OCD and BFRBs.

We specialize in treating OCD

Reach out to us. We're here to help.